10921 19TH AVE SE 2016-01-01 MF Import

� APPiication For PUBLIC WORKS PERMIT °a'P — PUBLIC WORKS DEPARTME?IT Public Works Pertnil N _ 3200 Cedar Street EveretL WA 98201 259-8010 Building Permit M_ ___ TfPE OR PRINT ONLY Pu61ic Works Fee$_ _ _— s111G�'�Z71 �i2'�i{.��(,� �a lc0o1 IlinAPN' (' m,+.�nn IZd .81�. L R», . 1D`t'S 5��, leltmcr� C�_ Owner Mailing Address City Zip Phone q��Q� _OQ m}�I.� ►��is'l+rzb7e • ��z5��4CLf�''� N 1�a11 ,vV� W/��_9? '�4l�'71 r'10 842-95� Applicant � _ Mailin9 Address City Zip Phone Describe Proposed Work 'h .Il 1'c', Ci��lr'• {71.u '.�,lil__��<_0_n_1_.C� � �, nh�2C�YLEb� �c7'IL�'(/�u � �L�F��V'Pc� �/�,/�_�1�,C7NA��,��1'1 .�i4 U1'C'�Y��2N'�� �rei��l� �i� _��is- 7 0- �6�� _ � , HROJECT ADDRESS (if known) �Q�� 1��• S•�• ' M Attach four(4)copies of plans for proposed work-Draw to scale and note the following if applicable: W •Propedy Lines •Outline and dimensions ot all existing and proposed s�mcWres on�he lot •Existing and proposed utilities O •Cen�edine of etreet •Indicate North •Show any p�oposed graCing changes •Show measuremen�s � DO NOT WRITE BELOW THIS LINE PERMIT CONDITIONS: Z 1. All calls for inspection shall be made 24 hours in advance - phone 259-8810. O 2.All work shall be pertormed in accordance with this permit and current City o!Everett Design and Construction Standards and Specifications. 3. Call Location Underground Service 48 hrs. before you dig. TOLL FHEE NUMBER 1-800-424-5555. � V/ O ":l�l�l: wo�ks r�r�ui a (�U ia R isfJ U�Sx`Siill � �4 f._�..��^ .�T�.. .:_�j�-�-�. _._._..r ACKNOWLEDGEMENT OF CONDITIONS The undersigned owaeNapplicant hereby agrees to hold and save harmless the Ciry of Everett from any and all ciaims tor damagea,costs,expenses,or Approved for Construction Date causes of action that may arise because of installation and maintenance of the improvement or other right-of-way use hereto applied tor and further agrees to remove same upon nutice from the City and to replace public property damnged thereby. FINAL INSPECTION Date Approved as Consiructed Sigra'ure of Applicant Date WORK AUTHORIZED E�THIS PERMIT MUST BE STARTED W'IFiN 780 DAYS OF DATE PERI IS ISSUED AND THEREAF�ER IS TO BE DIUGENTLY PURSU��TO � COMPLETION.THIS PERMIT MAY BE CANCELLED BY?':�CITY UPON ANY STOPPAGE OF >RK ON THIS PR0.IECT OVER 90 OAYS DURA770N.